1922463660 NPI number — KIMBERLY V. FOGARTY, LICENSED MARRIAGE & FAMILY THERAPY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922463660 NPI number — KIMBERLY V. FOGARTY, LICENSED MARRIAGE & FAMILY THERAPY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBERLY V. FOGARTY, LICENSED MARRIAGE & FAMILY THERAPY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922463660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
580 BROADWAY ST STE 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92651-4311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-424-9755
Provider Business Mailing Address Fax Number:
949-488-0344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 PACIFICO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA NIGUEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92677-4242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-424-9755
Provider Business Practice Location Address Fax Number:
949-488-0344
Provider Enumeration Date:
12/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FOGARTY
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
VERMILLION
Authorized Official Title or Position:
OWNER/PSYCHOTHERAPIST
Authorized Official Telephone Number:
949-424-9755

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  LMFT89459 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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